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UONpT_ <br /> QUADRUPLICATE STATE OF CALIFORNIA DWR SE LY — DO NF I L IN <br /> For Local Rgquirements WELL COMPLETION REPORT I I STATE WELL NO.STATION NO. <br /> page—' of 1 Refer to lnrtructia>z Pamphlet ❑ ❑ <br /> 500535 <br /> Owner's Well No. f j f ga LATITUDE LONGITUDE <br /> Date Work Began ,1Rd sental Realty! <br /> Locai Permit AD <br /> S ` AP l R <br /> Permit No. V Permit Date <br /> GEOLOGIC LOG -v=-antler A%S'Hi cin Inc• �! <br /> ORIENTATION (! VERTICAL — HORIZOf flo 3—ANGLE —(SPEGEFY) Name3577 - <br /> DEPTH TO FIRST WATER i•V••3(Ft.) BELOW SURFACE Iit�®ddress e* gine <br /> DEPTH FROM <br /> SURFACE DESCRIPTION STATE ZIP <br /> Ft. t i7ercribe rrraterial,grain rite,color,etc. <br /> CITY EbjjaC AT I O N <br /> dark Addrelp . <br /> • 1 ! i <br /> Imi -8htly p1sxtic, 20% veryCitySan joaquin <br /> County 1 <br /> to flits sand, alightlyAPN Book 2S Page�_Parcel <br /> • Township Range Section <br /> 9 or <br /> Latitude I NORTH Longitude wesT_ <br /> lie to f DEG. MIN. SEC. DEG. MIN, SEC. <br /> LOCATION SKETCH ACTIVITY (2L) <br /> 06 <br /> NORTH NEW WELL <br /> MODIFICATION IREPAIR <br /> ! V-7 wet. <br /> AW _Deepen <br /> • <br /> , ! - l lsh brown,to plastiev � �,.Other(Specify) <br /> , <br /> l_DESTROY(Describe <br /> , Procedures and Materials <br /> rUnder-GEOLOWC LOG") <br /> AW&RAWf same as @ 13 ` PLANNED USES) 1 <br /> ! . a X [�} <br /> T� ul MONITORING <br /> WATER SUPPLY <br /> • -•..•--•--=w=R� Domestic <br /> f _ Public <br /> � <br /> Irrigation� <br /> Intlustriel <br /> "TEST WELL" <br /> ' CATHODIC PROT£C- <br /> SOUTH TION <br /> 111usfrale or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING A <br /> METHOD FLUID <br /> WATER VkE <br /> DEPTH OF STATIC LV* & YIELD OF COMPL1r,1 ,4�49t) <br /> WATER LEVEL (Ft.) & DATE MEASURED / bG <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br />' TOTAL DEPTH OF BORING • q41) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELLy (Feet) May Trot 6e representative of a well's long-term yield. <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- <br /> FROM SURFACE HOLE TYPE j FROM SURFACE TYPE <br /> DIA. z o d MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z Z� a DIAMETER OR WALL IF ANY MENTTONITE FILL FILTER PACK <br /> Ft. to Ft. m N Oo � GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPEISIZE) <br /> • •40 • <br /> r57 <br /> * • • • • <br /> • <br /> 12/12 vark, <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> I,the and rsigned,certify that this re ort is complete and accurate to the best of my knowledge and belief. <br /> _ Geologic Log The Twining Laboratories, Inc. <br /> — Well Construction Diagram NAME <br /> (PERSON, FIRM, 6R CORPORAT40N) (TYPED OR PRINTED) <br /> GeophysicalLog(s) 2527 Fresno Street Fresno CA 93721 <br /> — Soil/Water Chemical Analyses _ <br /> ADDRESS J CITY STATE 19 <br /> Other � �4 1 ;f� f)� �. r,� ���� 506 <br /> ATTACH ADDinONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWI;188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />